The Challenge Initiative
Stories of Scale and Sustainability in Family Planning and Beyond
This collection of stories is drawn from The Challenge Initiative’s (TCI’s) primary qualitative method called the Most Significant Change (MSC) technique. The stories were collected between April 2019 to March 2020 and were ultimately selected as demonstrating sustainable scale-up potential. While the overarching purpose of TCI is to rapidly meet women’s and couples' unmet need for modern contraception, it aims to affect changes in the health system along the way to ensure the results are sustainable, even after TCI involvement in a particular city diminishes and eventually ends. Therefore, in addition to measuring scale-up in the traditional sense of number of cities and population reached, TCI has identified the following four key pillars to measure its progress toward sustainable scale-up of high-quality family planning programming and outcomes. These four pillars can serve as early indicators that the results, interventions and new ways of thinking will have lasting impact.
About This Collection
The KM team would like to acknowledge all of those who supported the MSC data collection efforts, including the individuals involved in the MSC story collection and selection processes as well as the interviewees. Design: Elizabeth Tully Technical inputs and review: Lisa Mwaikambo, Sarah Brittingham and Kim Martin Photo credits: TCI, Images of Empowerment
Acknowledgements
Stories
INCREASED POLITICAL & FINANCIAL COMMITMENT
Pillar 1
SUSTAINED DEMAND
Pillar 4
CAPACITY STRENGTHENING
Pillar 2
INSTITUTIONALIZATION OF TCI PROVEN APPROACHES
Pillar 3
TCI represents an exciting new approach to rapidly and sustainably scale up high-impact reproductive health solutions in poor urban areas of low- and middle-income countries. TCI works through four regional hubs in East Africa, Francophone West Africa, Nigeria and India that support learning and continuous improvement at three levels – the city, hub and platform/initiative – and with multiple stakeholders. TCI is led by the Bill & Melinda Gates Institute for Population and Reproductive Health in the Department of Population, Family and Reproductive Health at the Johns Hopkins Bloomberg School of Public Health. TCI’s regional hubs are led by IntraHealth International in Francophone West Africa, the Johns Hopkins Center for Communication Programs (CCP) in Nigeria, Jhpiego in East Africa and Population Services International (PSI) in India.
About TCI
2020
Political commitment strengthens the enabling environment and facilitates scale, or at a minimum eliminates barriers to scale up. With political commitment comes development of operational and national policies, implementation of supportive programming environments and systems, and obligation of the necessary financial resources, helping to set the stage for sustainability. TCI aims to transform political will into local ownership and, as a result, local accountability whereby governments lead family planning efforts in their geography. This starts with TCI's demand-driven process whereby cities not only express their interest in joining TCI and sharing its Business Unusual mindset, but also commit their financial and human resources to scale up proven family planning interventions. TCI has made great strides in this realm.
PILLAR 1
Increased Political & Financial Commitment
MOBILIZING SIGNIFICANT FINANCIAL RESOURCES FOR FAMILY PLANNING
Nigeria
ENGAGING POLITICAL LEADERSHIP IN YOUTH REPRODUCTIVE HEALTH
Francophone West Africa
USING DATA AND ADVOCACY TO INCREASE INVESTMENT IN FAMILY PLANNING
East Africa
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MAKING URBAN PRIMARY HEALTH CENTERS ADOLESCENT-FRIENDLY
India
Back
Capacity in global health – the ability to carry out stated health systems objectives – is believed to contribute directly to improved performance in global health and to play an important role in sustaining adequate performance over time. Capacity strengthening is the process that improves the ability of a person, group, organization or system to meet its objectives or perform better. TCI aims to strengthen capacity at the systems, organizational and individual levels. Read the stories below that demonstrate this increased capacity as a result of TCI.
PILLAR 2
Capacity Strengthening
STRENGTHENING CAPACITY TO IMPLEMENT YOUTH RH PROGRAMS
INCREASING USE OF LONG-ACTING REVERSIBLE CONTRACEPTIVES
STREAMLINING PROVISION OF HEALTH CARE THROUGH COACHING
ACHIEVING IMPACT IN URBAN FAMILY PLANNING PROGRAMS
Institutionalization is the integration of a program or intervention within an organization and is considered an important indicator of long-term sustainability. Sometimes referred to as “vertical” scale-up, institutionalization under the TCI context ensures that implementation of evidence-based family planning and adolescent and youth sexual and reproductive health (AYSRH) interventions and the TCI guiding principles becomes the new norm in all sub-systems of the health system, including policies and procedures, human resources, financial and managerial.
PILLAR 3
Institutionalization of TCI Proven Approaches
ENHANCING QUALITY DATA FOR DECISION-MAKING
IMPROVING ACCESS TO FAMILY PLANNING THROUGH COLLABORATION
RESTORING HOPE THROUGH THE 72-HOUR MAKEOVER APPROACH
UNLOCKING BENEFITS OF 'ESSENTIAL SPACING AT BIRTH' SCHEME
Demand for modern contraception provides an indication of modern contraceptive use in a population plus an important segment of the population that likely has favorable attitudes toward family planning and for whom family planning programs need to reach with services. Persistence of demand for modern methods, therefore, represents that acceptability and use of modern methods has become normalized in the local culture and will likely lead to increases in modern contraceptive method uptake. As a result, the stories highlighted in this domain focus on increased access and improved quality of family planning services leading to increased uptake.
PILLAR 4
Sustained Demand
MOBILIZING FAMILY PLANNING THROUGH RELIGIOUS LEADERS
MAKING FAMILY PLANNING PART OF THE DAILY ROUTINE
STRENGTHENING COMMUNITY OUTREACHES THROUGH COACHING
RECOGNIZING CHAMPIONS FOR PROMOTING MALE FAMILY PLANNING METHODS
Authors:
Family planning (FP) is a major cost driver to the health status of a county. It improves maternal and child health, facilitates educational advances, empowers women and families, reduces poverty and is a foundational element to the economic development of the county and nation at large.
Using Data and Advocacy to Increase Investment in Family Planning
Why This Story Is Significant
TCI was a catalyst to government ownership, demonstrating sustainability and local ownership Good example of data use to strengthen commitment
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E A S T A F R I C A
Investment in FP is a clearer way of ensuring that we rduce incidences of maternal deaths, and by extension, decrease suffering by women and children. – Hon. Gideon Saburi, Deputy Governor- Kilifi County
To ensure ownership and sustainability for FP and AYSRH services, the County Government has adapted a number of TCI proven interventions, including in-reaches, youth special FP days, community dialogues and data quality audits in its annual work plan and as part of its AYSRH strategic plan 2018-2020. The County budget committee for health, will ensure continued increase in resource allocation and utilization for FP/AYSRH interventions. The department of health will continue to mobilize partners who wish to support Kilifi County even in areas beyond FP/AYSRH to adopt the TCI model. Currently, Plan International have adopted a number of TCI proven interventions as part of its AYSRH program in Kilifi.
With Kilifi County being ranked among the poorest counties economically and among the most poorly performing counties in reproductive health indicators, the county government needed to collaborate with the development partners to reduce the negative indicators in FP and teenage pregnancy/GBV (gender-based violence) issues. TCI’s business model came in at the right time, and as a County, we had to adopt the interventions to start the journey in reducing our negative indicators in FP/AY. Initiatives, like that of TCI, are hard to come by; the TCI model acted like a trigger for the county government to continue investing in youth, and in particular, reproductive health programs targeting them. We know TCI will not last forever and this calls for us, as government, to sustain the programs, thus increased budget allocations. Over the years, we have increased our allocation to FP and AYSRH; for instance, we increased AYSRH resources by over 100% from the last financial year. The department of health now has a dedicated staff to coordinate AYSRH interventions across the County. – Hon. Gideon Saburi, Deputy Governor- Kilifi County
On a quarterly basis, the Kilifi Country Program Implementation Team (PIT) that oversees TCI implementation share their reports with the County leadership to review the performance of FP/AYSRH indicators against the investments made.
Levis Onsase, TCI EA hub Kenneth Miriti, TCI EA hub Njeri Mbugua, TCI EA hub Sama Denis, TCI EA hub
Based on the data reviewed, we were able to determine that we needed to provide FP services in hard-to-reach areas in some parts of the County; hence, we allocated some funds (KES 1.6M) to support FP integrated outreaches in quarters three and four. As with challenge of commodities, we have continued to mobilize our partners, such as MSK and Afya Pwani, to support and redistribute commodities across facilities whenever we are stocked out. – Dr. Anisa Omar, CECM Health - Kilifi County
Decision makers in Bénin municipalities have faced challenges for many years on how to prioritize development needs, often times focusing on infrastructure construction rather than on health programs. TCI caught the attention of one such leader, President Luc Sètondji Atropko, because of its human-centered approach. He appreciated that TCI reminds him and is fellow decision makers of their role and duty to promote child and youth health, including reproductive health.
Engaging Political Leadership in Youth Reproductive Health
Notable engagement of President of municipality Demonstrates support for youth reproductive health programming Shows powerful advocacy in action
F R A N C O P H O N E W E S T A F R I C A
Mayors decided that working on this issue is their duty. They took ownership of the matter and did their best to convince as many councilors as possible. As soon as their work paid off, we all decided to allocate funds to the youth project because we believe that the youth today are the Benin of tomorrow. We are convinced that if the youth are more educated, there will be more equipped and educated executives. From now on, we are planting a seed today to harvest the fruits tomorrow. We are doing it through this project so that collective awareness can be real in this field. Today, significant efforts are being made, I think that our experience at the Union des communes du Zou helped us at the Association nationale des communes du Bénin to have a family planning program with the International Association of Francophone Mayors. – President Atropko
Mayors and decision makers also had to overcome the sociological environment and address those issues and taboos related to youth reproductive health.
I think that with the TCI project, our perception of things has changed. I just talked about councilors, they took ownership of the project after being trained and sensitized. The youth in general and young leaders are more and more responsible; as you see them taking part in activities, you can see that they are willing to do their best. The Zou department has been facing challenges. Surveys conducted lately showed that in terms of pregnancy in schools, the Zou department ranked 2nd out of 12, hence the need for awareness raising and education. I think that this project came at the right time. Today I think that things are getting better through education and awareness raising; this works together for the good of the youth and the development of the community. – President Atropko, Union of the Zou Municipalities | President, National Association of the Bénin Municipalities | Mayor
President Atropko has begun the process of taking what was done at the district level to the national level. Working with mayors who were recently elected as MPs, they will advocate for family planning and youth reproductive health to be embraced within Bénin's city councils.
Fatima Sow, TCI FWA hub
I think that raising awareness among city councils is the assurance of the project sustainability. As soon as city councils are fully equipped and take ownership of this role, it will be easier in the future to include this thematic, child health, reproductive health and so on, in our budget items. – President Atropko
F W A
In Prayagraj city (Allahabad), the walls of Daranganj urban primary health care center (UPHC) reverberate with the sound of excited chatter, laughter and happy noises. It is the eighth of February and Daraganj UPHC is all set to host an Adolescent Health Day (AHD), a dedicated day for unmarried adolescent boys and girls age 15 - 19 years to seek a variety of health services and engage with facility staff. Facility AHD is one of the strategies under Rashtriya Kishor Swasthya Karyakram (RKSK), a Government of India (GOI) program launched by the Ministry of Health & Family Welfare to improve health seeking behavior among young unmarried adolescents, 10-19 years of age. However, RKSK guidelines emphasize that facility AHDs can only be conducted in facilities that are classified as adolescent-friendly health centers (AFHCs), which are currently limited to secondary and tertiary care facilities such as district women hospital and medical college. Limiting services to higher level of care facilities restricts linkages between primary and speciality care services, especially for vulnerable populations, like unmarried boys and girls and the urban poor.
Making Urban Primary Health Centers Adolescent-Friendly
TCIHC sparks change to conduct AHD for the first time in urban areas of Uttar Pradesh Demonstrates city governments' political and financial commitment to the approach through issuance of directives
I N D I A
Until this WSO happened, I had never thought that something special needs to be done for adolescents. In fact, all the staff of this facility never felt that adolescents have any such [contraceptive] need. However, I realized that adolescents also have this need when I saw 60 boys and girls turn up on the day of AHD. – Medical-Officer-In-Charge (MOIC) of Shahpur UPHC, Gorakhpur
To address this challenge, The Challenge Initiative for Healthy Cities (TCIHC) is supporting RKSK program to establish urban primary health centers (UPHCs) as AFHCs in five TCIHC-supported cities – Allahabad, Firozabad, Gorakhpur, Saharanpur and Varanasi. A critical feature of an AFHC is the presence of a dedicated counselor for adolescent services. Working with the Chief Medical Officer (CMO), TCIHC identified one staff nurse from each of the 96 UPHCs in the five cities and strengthened their capacity to provide adolescent health counseling, following RKSK curriculum. In addition, a staff-wide whole site orientation (WSO), which ensures that all staff have a basic understanding about adolescent and youth sexual and reproductive health needs, was conducted in each of the 96 UPHCs to guarantee a welcoming and accessible environment for unmarried youths to access sexual reproductive health (SRH) information and services. Nearly 1,300 UPHC staff, including doctors, staff nurses, janitors and pharmacists, were oriented on providing SRH information and services to both married and unmarried adolescents and youth, 15 - 24 years of age, as a result.
I always thought it is only when one is sick we go to a clinic. One can also go to a clinic when we need information about our health is something I just came to know. – A 15-year-old girl who attended the AHD at the Daranganj UPHC
As of February 2020, facility AHDs have been conducted in 70 UPHCs across the five cities with close to 2,500 youth in attendance. Given the questions asked by youth during the AHDs, medical officers of UPHCs have asked ASHAs to inquire as to the health needs of adolescents during their household visits – something which had never happened before. In addition, the demonstration of facility AHD have grabbed the attention of government officials. As a result, Chief Medical Officers of Allahabad, Firozabad, Saharanpur and Gorakhpur have issued directives to conduct facility-based AHDs on the eighth of every month across all UPHCs in the city.
Ipsha Singh, TCIHC Deepti Mathur, TCIHC
Prior to the support of family activities by TCI in Plateau State, the state had only recorded a release of 5 Million Naira within a 4-year period from 2014 to 2018, despite support from other partners to ensure domestic funding. The inception of TCI in the state ensured a rejuvenated Advocacy Core Group (ACG) who were registered as a Civil Service Organization. TCI funded and trained ACG members on Visioning and Smart Advocacy aimed at developing their capacity in using smart advocacy skills to engage policy makers to ensure provision of an enabling environment for FP. The training focused on advocacy to ensure domestic funding and release of allocated funds in the state family planning budget. In addition, following the just concluded election in the state, TCI also supported the state to form and inaugurate a 20-person budget task team (BTT) whose capacities were built on state budget processes including budget planning and releases. Within two weeks of the formation and training of the 20-person BTT, members of the team and ACG conducted advocacy visits with support from TCI to engage with key policy makers. This resulted in the release of 43.5% of the total 2018 budgeted sum of 23 Million Naira for family planning by the state government despite a politically charged climate. The released budget is currently being used to implement TCI high impact family planning interventions within the integrated state family planning workplan, while the BTT is currently monitoring and ensuring judicious utilization of the funds. In addition to formal budget release, the Plateau State government is increasingly finding opportunities to mobilize additional resources to implement its family planning program. This was seen with the sponsorship of the LARC training for 19 assistant LGA RH coordinators by the Plateau State Primary Health Care Board (PS-SPHCB).
Mobilizing Significant Financial Resources for Family Planning
Demonstrates a responsive government that owns up to their roles and responsibilities for the benefit of the public Government commitment to improving quality of care
N I G E R I A
It is high time we (government) begin to take the lead in the implementation of proven strategies geared towards universal health care coverage through the allocation and release of funds, especially in the area of family planning which when effectively implemented will improve access to modern FP methods and reduce the incidence of maternal morbidity and mortality significantly. – Executive Secretary-PHCB
He went further to stress that the state was willing to invest in high-impact family planning interventions as he has been exposed to TCI's business unusual way of doing things. As a TCI ambassador in the State, he stated that he is ready to institutionalize best practices and foster sustainability through ownership. The sum of One Million Eight Hundred Thousand naira (1800,000NGN) was released to support the LARC training and the practicum session which further equipped them for service delivery.
Dr. Philemon Yohanna, TCI Nigeria hub
This training has built my capacity in LARC and given me confidence in undertaking my duties as a service provider, now I know what to do and how to do it. – Esther Shoibal, Deputy RH Coordinator, Langtang South Local Government
At the end of the training, participants were asked to develop a six-month sustainability plan for adoption by state. This is significant because not only is the state leadership taking lead of the process and releasing funds other than the family planning budget line, but a further step on institutionalization as seen when participants were asked to develop a sustainability plan for LARC program implementation at LGA level for adaption by the PSPHCB.
Kylie Gyubi, a registered nurse working at TCI-supported Moivo Dispensary in Arusha District Council, is passionate about saving lives but previously had limited knowledge and skills in family planning. One day, Kylie was selected to join two other health providers from her district to attend a three-day south-to-south learning exchange visit in Dar es Salaam organized by TCI, dubbed "Sisi kwa Sisi," which when translated means "us for us." While in Dar es Salaam, Gyubi and her colleagues learned how the local governments of Ubungo, Kigamboni and Temeke were implementing TCI high-impact best practices.
Streamlining Provision of Health Care Through Coaching
Shows diffusion of TCI's high-impact interventions, hence, sustainability Improvements in staff capacity to provide services Demonstrates scale-up of best practices without additional resources through south-to-south skills transfer
We visited Ubungo, Kigamboni and Temeke municipalities, where we were exposed to various key impact areas, such as how they are providing friendly services to youth, empowering unskilled attendants – like watchman, cleaner, and other technical staff – on the basic information needed while attending to clients at the facility. We also learned how they conduct outreach and in-reach services, including having a special day dedicated to working clients who can’t attend services on weekdays.. Every day [of the visit], I imagined how helpful it would be if I adopted some of these approaches. – Kylie Gyubi
When Gyubi returned from the learning visit, she adopted some of the innovations that she had learned with the aim of transforming her dispensary in Moivo. Almost immediately, she started training and mentoring her fellow providers, particularly on providing youth-friendly services.
Owen Mwandumbya, TCI EA hub Denis Sama, TCI EA hub Rose Mnsava, TCI EA hub
To ensure effective diffusion, the team prepared a checklist with items that they thought would be ideal for each facility in the district to learn and improve by adopting TCI innovations from Moivo Dispensary. In the checklist, they considered if each facility has privacy and any plan on how to enroll youth or facilitate youth-friendly services. They visited and oriented staff from 15 TCI-supported facilities with coaching and mentorship on how to conduct community dialogues, outreaches, in-reaches and data management. TCI's high-impact best practices are now being adapted beyond the 15 health facilities with the hope that expansion can go beyond Arusha District.
Within less than two months, Moivo Dispensary had established youth-friendly services and formed a group of pregnant women below 25 years, where they were able to access reproductive health services alone and in privacy. We expanded our in-reach service by dedicating Saturday to those women who are busy with other economic activities within working days. One day our District Nursing Officer, Mrs. Augusta Komba, visited our facility and she was so happy to see that we were transforming Moivo Dispensary with innovations adopted during “sisi-kwa-sisi” learning visit in Dar es Salaam. Mrs. Komba wanted all nurses from her district to learn from Moivo Dispensary. So, during the commemoration of the International Nursing Day, she organized a learning visit for all the nurses to Moivo Dispensary. – Kylie Gyubi
The Challenge Initiative (TCI) began a fruitful collaboration with the Senegalese municipality of Nioro in December 2017. To increase access to family planning, Nioro prioritized and implemented the following TCI proven approaches when designing their program – universal referral, improving commodity management and supplies, and strengthening provider capacity, especially in the provision of long-acting reversible contraceptives (LARCs), to best meet the population’s needs. Word spread quickly that family planning and other essential services were not readily available at public health facilities due to a strike from April 2018 to December 2018. Slowly, women started to adapt their preferences to this new reality, opting for LARCs so they could obtain optimal protection without having to return to the facility often. Fortunately, Nioro had prioritized LARCs when originally designing its program and work plan with TCI. As a result, providers were trained on LARCs and the city provided the needed commodities by June 2018. The team developed a plan based on TCI’s proven approach to support communication for family planning with community activities such as home visits and religious leaders to support Nioro’s rebound and hopefully reverse the decline in family planning uptake caused by limited service availability in the district. Sadio Baye Mbaye – the municipality’s Reproductive Health Coordinator – along with the district health education officer supported stakeholders at the community level, such as religious leaders and community health workers, to implement demand generation activities between January and March 2019. Together, they trained four religious leaders (who then organized 12 awareness-raising sessions for other religious leaders), strengthened the capacity of 30 community health workers to conduct home visits and oriented 50 council members on family planning advocacy. Recent data from the health management information system shows that in December 2019, annual family planning client volume had increased by 14% from its lowest point in March 2019.
Increasing Use of Long-Acting Reversible Contraceptives
Demonstrates how building provider capacity in LARCs coupled with the implementation of other high-impact demand generation interventions led to an increase in family planning service uptake
Adama Seck, TCI FWA hub Sarah Brittingham, TCI KM team
After an evaluation of our indicators in the Kaolack medical region, we can see an improvement in our indicators compared to the other three districts…. We are lucky that the TCI project supports us. Its area of intervention is …. Nioro district. The other districts have no partner that only focuses on FP. Nioro is fortunate to have a project that only focuses on FP… I think the new action plan which is being developed will allow us to sustain this momentum… It will improve the indicators and it will have an impact on the population we work with because FP is the first pillar to fight against maternal and neonatal mortality. – Sadio Baye Mbaye
Dr. Pravin Kumar Bharti, Deputy Chief Medical Officer and Nodal Urban Health, National Urban Health Mission (NUHM) in Mathura, Uttar Pradesh, first learned about The Challenge Initiative for Healthy Cities (TCIHC) and TCI University (TCI-U) at a TCIHC-organized State Conclave that endorsed nine high impact approaches (HIAs) for urban family planning. As a result of that event, Dr. Bharti registered himslef and his colleagues on TCI-U with the support of TCIHC City Manager.
Achieving Impact in Urban Family Planning Programs
Depicts how government officials are able to not only obtain practical tools and aggregated information based on government guidelines on TCI-U but also download, use and share specific tools from TCI-U with other relevant facility-level stakeholders
I developed a keen interest in TCI-U when during a meeting in March 2019 with the Chief Medical Officer, he required some job-aids related to Accredited Social Health Activists (ASHA) and he asked TCIHC City Manager for support. TCIHC City Manager quickly browsed TCI-U and downloaded the required information from the resource section linked to the HIA on Urban ASHAs. I was impressed. And, from that day onwards, I have kept hard copies of the HIAs on my desk and access them on TCI-U as well. – Dr. Bharti
The high impact tools helped his department understand fixed day static/family planning day (FDS) approach, role of Mahila Arogya Samiti in demand generation for family planning, importance of convergence between various departments for improving family planning indicators, use of family planning data, funds allocated under Program Implementation Plan (PIP), among others. He also downloaded government-approved materials from TCI-U that are now displayed in all urban primary health centers of Mathura and provided all staff nurses and community health workers with the pregnancy screening checklist to help them identify potential family planning and antenatal clients.
Dharmendra Tripathi, TCIHC Parul Saxena, TCIHC
Urban family planning requires a lot of innovations and TCI-U is one such platform that provides innovative proven approaches. I like everything about TCI-U because it helps to understand our roles better, provides ways to get quick results and offers solutions to overcome potential challenges. That it is my job to improve family planning indicators and take decisions. TCI-U helps me do that. – Dr. Bharti
Like Dr. Bharti, there are around 35 government officials registered on TCI-U from Mathura and most of them have completed HIA assessments and received certificates.
TCI-U has helped me improve family planning practices across cadres, including NUHM [National Urban Health Mission] staff to field-level workers. I also navigate TCI-U to learn other countries’ innovations and ideas also. – Dr. Bharti
As a result of this increased capacity and confidence, Hajia Fati now knows how to more effectively work with other line ministries and coordinate civil society organizations to carry out youth-focused activities. She monitors and tracks implementation progress, providing proper documentation to ministry leadership and other line ministrie. In addition, she has attracted funding from other implementing partners, such as Pathfinder International and Education as a Vaccine (EVA). With TCI’s coaching support, Hajia Fati has also achieved professional growth milestones: presenting for the first time on the AYSRH work going on in Niger state at the Adolescent and Youth Family Planning Conference held in Ibadan in March 2019 and the National Conference on Adolescent and Youth held in Abuja in May 2019.
Strengthening Capacity to Implement Youth Reproductive Health Programs
Demonstrates transfer of skills and capacity to both the individual and the office that oversees adolescent health, leading to likely institutionalization of capacity Highlights the effectiveness of continuous coaching on the individual's and institution's productivity
Glory Omomase, TCI Nigeria hub
Prior to TCI’s support for AYSRH intervention in Niger state, I knew that adolescents and youth are a huge chunk of unmet need for FP, but I knew little or nothing about strategies and approaches to reach them. In the past 12 months, TCI built my capacity on ways to engage these youth and make services available for them. I used to be a shy person and experience stage fright, but since engaging with TCI, I have built my self-confidence and can speak publicly. – Hajia Fati
Although the Adolescent Health & Development (AHD) office existed prior to TCI’s engagements with Niger state, it was not fully functional. The Adolescent Health Desk Officer (AHDO), Hajia Fati Gogo, came to the position with a clinical background, having never served as a program manager before. As a result, she was unsure how to do program management and effectively oversee the AHD office, which was fairly new. TCI coaching has provided Hajia Fati with opportunities to develop and strengthen skills not only related to AYSRH program design and implementation but also related to coordination, presentation and public speaking.
Following the makeover, the Permanent Secretary of the Ministry of Health visited the facility and upgraded it from level II to level III. The creation of a family planning unit has led to a significant increase in clients and a change in the mindsets of the surrounding Muslim community as there is continuous awareness raising about family planning and debunking of myths and misconceptions. Likewise, the demand for maternal health and immunization services have increased. Staff now receive regular pay and are more committed to their work, with a government staff person now being seconded to support the maternity unit.
Restoring Hope Through the 72-Hour Makeover Approach
Demonstrates local ownership of health system strengthening by government and PNFP partner providing funding for implementation of a TCI proven intervention Exemplifies the value add of TCI in garnering community involvement in the implementation of TCI proven intervention Shows the impact of facility improvements in improving staff morale and service uptake of family planning and other health services
Janet Adongo, TCI EA hub Sama Denis, TCI EA hub
Our moment of change and excitement only came when KCCA Kawempe Division and TCI came to assess the facility. They told us that since this is PNFP [private-not-for-profit] under the Muslim community, if they can give some support, the facility would receive a new facelift within 72 hours.... We convened a meeting with the Health Unit Management Team and told them what was told to us. The team was very excited and the leaders.... started the process by drawing up a budget and brainstormed where they could get some money. When we got a confirmation of this activity, the staff and the community were more than ready to support the activity. The Muslim community decided to start work small. We anxiously looked forward to see the team from TCI and KCCA appear on the ground. The vison came to pass when we saw the materials and the team. We all worked trans-nights and days to beat the deadline of 72 hours. There was unimaginable change at the facility. People who never witnessed the work going-on could not believe the miracle of change – Faisal Ssali
As staff of Kawempe Mbogo Health Center II, we had given up hope and did not ever imagine we would have life in this facility as health workers.... The facility was in an almost condemned building.... Clients were very-very few and we practically had no work. We would go without pay for several months. And, if we got paid, it would be in installments because there was no money the facility was generating from its operations. The facility itself was in a terrible state for one to enjoy working or living in or around it. – Faisal Ssali, In-charge Kawempe Mbogo Health Center, Kampala
In the 1980s, Mbogo Muslim Memorial Community Center, located in Kampala, started Kawempe Mbogo Health Center II to address the health needs of its community. Over time, this facility became dilapidated, and was no longer attractive or safe for the public and health workers. Consequently, its revenue dropped and it was at the verge of closing.
In May 2019, Kampala Capital City Authority (KCCA) with support from TCI renovated this health facility using the 72-hour clinic makeover approach.
As of December 2019, HMIS data from Ziguinchor reveal a 24% increase in annual family planning client volume, reversing a negative trend from its lowest point in March 2019. Similarly, for LARC clients, there was a 28% increase. The data suggest that the incorporation of TCI’s proven approaches in Ziguinchor’s annual action plan has contribute to the improvements in the city’s family planning indicators.
Improving Access to Family Planning Through Collaboration
Shows the power of collaboration between health system and city government Demonstrates sustainability through the city-funded and hiring of two midwives
Hawa Talla, TCI FWA hub Sarah Brittingham, TCI KM team
TCI taught us how to work with the city and showed us how to mobilize key actors for family planning and maternal health programs. – Dr. Maodo Malick Diop, Chief Medical Officer
Ziguinchor, a city in southern Senegal, has historically struggled to meet its family planning targets. One of the reasons may be that the health system and the city government did not collaborate to support family planning interventions. While the city government was providing medications to districts, those did not include family planning commodities. Meanwhile, the health system received limited support from international and national non-governmental organizations. In December 2018, Ziguinchor joined The Challenge Initiative (TCI). One of the first steps taken by TCI was to coordinate a new family planning collaboration agreement between the city and the health system, initiating a fruitful partnership. The agreement clarifies objectives, expected results, and roles and expectations of each sector to ensure an effective working relationship and joint accountability.
Since joining TCI, Ziguinchor has made unprecedented contributions to support reproductive health. The city’s increased financial contribution has filled critical gaps in health system funding to enable demand generation activities and improve the quality and availability of services. Newly available funds from the city allowed the health system to hire two midwives specially trained in the provision of long-acting reversible contraceptives (LARCs) and meeting the needs of adolescents and youth, purchase contraceptives to meet demand from Family Planning Special Days and strengthen provider capacity in TCI’s signature universal referral approach.
Until TCI arrived, the city did not fund family planning activities and was not involved in promoting family planning. – Dr. Diop
Historically, family planning in India has been dominated by female sterilization, and Accredited Social Health Activists (ASHAs) receive monetary benefits when they accompany women and men for sterilization. However, the unmet need for spacing births is highest, especially among young married women between 15- to 24-years-old. The Government of India (GoI) established the Essential Spacing at Birth (ESB) benefits to encourage birth spacing and for the promotion of long-acting reversible and other temporary contraceptive methods. The ESB scheme provides a result-based benefit to ASHAs who counsel newly married couples and first-time parents on the benefits of child birth spacing and contraception. While the ESB scheme was extended to urban ASHAs, they had not been able to reap any ESB-related benefits since it was neither well-understood by them nor by their supervisors, Auxiliary Nurse Midwives (ANMs). Hence, ESB scheme reported almost no claims at the time in which TCIHC began its support to the cities of Uttar Pradesh from 2016 to 2018. TCIHC saw this as an opportunity not only to serve potential clients with the full choice of methods, meeting the unmet need of a great proportion of women, but also motivate ASHAs by unlocking resources that the GoI had already committed for this cause. TCIHC uncovered scheme-related nuances and supported city and state officials to provide orientation to ASHAs and ANMs on the ESB scheme and simultaneously advocated with the family planning division at city and state levels to activate ASHA ESB benefits provided under the scheme. At the outset, ASHAs felt that the scheme involved complicated paperwork and multiple levels of approvals. TCIHC coaches worked with ASHAs to help them promote informed choice when counselling women by explaining spacing methods as well as permanent methods during their household visits. Besides this, TCIHC coaches demonstrated the effectiveness of the urban health index registry (UHIR) to record information that can be easily retrieved when submitting claims. The coaching built AHSAs' understanding of the ESB scheme as an investment with long-term returns and little to no extra effort. One such urban ASHA has served in Firozabad since September 2016. With over three years of experience, she is familiar with and regularly updates her client records and UHIR. However, she was not aware of the ESB scheme. With the coaching that she received from TCIHC, she was able to gather evidence and supporting documents to make ESB claims.
Unlocking Benefits of 'Essential Spacing at Birth' Scheme
Illustrates how TCI helped the government to activate its 'Essential Spacing at Birth' scheme in urban areas Demonstrates how TCI influenced frontline health workers' behavior to provide counseling on the full range of family planning methods
Meenakshi Dikshit, TCIHC Nitin Dwivedi, TCIHC Devika Varghese, TCIHC Vivek Dwivedi, TCIHC
Earlier I did not know that I could get an incentive if a couple in my area delays their first pregnancy or spaces subsequent births... Now I have a priority list of clients and I update my eligible couple list very carefully to claim the benefit. – Hemandri, urban ASHA, Firozabad
Enhancing Quality Data for Decision-Making Through TCI Coaching
Reveals the intentionality and systematic approach that TCI has taken in providing coaching to effective management and M&E Illustrates the institutionalization of DQA for family planning at the facility level
Beeve Hua, TCI Nigeria hub
In Bauchi state, data quality was identified as an issue that affected health care programming. The issue was widespread and originated from the point of data collection at health facilities. M&E officers based at the local government areas (LGAs) are tasked with validating data from the health facilities; however, the process of transmitting data from the health facilities to the LGA M&E officers takes time resulting in the lack of timely and accurate data. To mitigate this challenge, TCI provided coaching and technical assistance to the Bauchi State Primary Health Care Development Agency (BSPHCDA) to train LGA M&E officers to carry out Data Quality Assessment (DQA) exercises in health facilities instead of conducting DQAs on a quarterly basis. The training was conducted by TCI in Bauchi state in four rounds between June 2018 to December 2019.
Before the coming of TCI to the state, there used to be a quarterly DQA, however, it was mainly for routine immunization and other programs, but with the technical support from TCI, the state invited all the LGA M&E Officers and trained them to conduct DQA for family planning and since then, the time we spent on ensuring the quality of family planning data has been reduced significantly. It is now done within a day because the DQA is done at the facility level. – Sumayya Suleiman, Bauchi State Family Planning M&E Officer
There were a lot of partners supporting the LGAs in the state before the coming of TCI. Each partner comes with their own tools for DQA because they wanted a specific data, and it wasn’t just cumbersome, it was also difficult to understand all the tools. When TCI came, they simplified the tools, trained us and we went ahead to train the facility providers on how to apply the tools to check data quality before it is submitted to me. Now we know the effectiveness of the DQA, I have trained some of the services providers that are not at TCI- supported facilities and all these facilities that are conducting the DQA, their data has improved and it does not take me more than a day to validate their data. – Hamisu Shehu, Bauchi LGA M&E Officer
The trained LGA M&E officers cascaded the training they received to officers at the health facility to ensure increased quality of data collected at the facilities. As a result, quality and timeliness of data reporting has improved in Bauchi state.
The poor utilization of data for decision-making exacerbated low uptake of family planning services in Embakasi Sub-County.
Strengthening Community Outreaches Through Coaching
Demonstrates the on-demand coaching aspect of TCI Illustrates impact of enhanced capacity Shows tangible results translating into increased access
Magdalene Mbondo, TCI EA hub Denis Sama, TCI EA hub
We used to take services to the underserved communities especially in the slums. However, family planning was not actively integrated into our outreaches because we thought it was not important. Community stakeholders were not involved in the planning of outreaches. Our mobilization strategy was also not focused as we used to mobilize clients for all health services. Consequently, we ended up with more clients receiving curative services other than family planning and we hardly achieved our family planning indicators. – Pauline Ochola, Embakasi East Sub-County, Nairobi
Embakasi East Sub-County in Nairobi has informal settlements where many have limited access to health facility services. This sub-county uses integrated family planning outreaches based in the community to reach the underserved population. Initially, family planning was passively integrated into the existing community outreaches, which resulted into minimal uptake of family planning services.
We thought that we knew how to conduct outreaches, so we were not using data to guide our decision-making. The decision of where to conduct the outreach was based on other factors, rather than data. There were no review meetings after the activity and CHVs [Community Health Volunteers] were not given guidance for outreaches. This translated into poor planning and preparation. – Pauline Ochola
After realizing their problem, the Embakasi Sub-County health team approached TCI East Africa hub - for coaching on its way of implementing its proven integrated family planning outreach intervention. Using TCI’s coaching approach, locally referred to as Sisi-kwa-Sisi, TCI coached the health team on how to conduct effective integrated family planning outreaches using TCI University.
The poor performance of our outreaches prompted us to request for coaching on outreaches from Tupange Pamoja. We were paired with two Sisi-kwa-Sisi coaches who coached us on how to conduct high yielding integrated FP outreaches. We were all registered in TCI-U and coached on how to navigate it. We were also coached on the integrated FP outreach and demand creation using the TCI-U toolkit.
After the coaching, our outreach numbers have multiplied by more than three times. The Sisi-kwa-sisi coaching was an eye opener because it helped us to identify the gaps that we were having in demand creation and service delivery. We have now started conducting targeted outreaches and we only integrated 2-3 other services to avoid losing focus. We are now referencing TCI University toolkit to ensure that we are adopting what has proven to be the best practices. In our first community outreach after the coaching, we surpassed our target of 80 FP acceptors and instead achieved 391 FP acceptors followed by 285 FP acceptors in the consecutive outreach.... Now more women and girls are being reached with family planning services, hence reducing the number of unintended pregnancies.... – Pauline Ochola
Making Family Planning Part of the Daily Routine
Illustrates high-impact approach of ISBC with clarity, including simplicity of tools Contributes to women's empowerment Elevates sustainability and local ownership
Sarah Brittingham, TCI KM team
Today, in the city of Bouaké and the surrounding urban areas, all providers have been oriented on how to talk about family planning after providing any service. This comes after TCI introduced one of TCI's high-impact approaches in family planning, systematic identification of client needs (ISBC), to the health providers in the city.
Before TCI, family planning services were provided, but differently - they were only available at the family planning unit, and not across all points of service. In the past, it was not part of provider's habit. Today, with ISBC, women are informed about family planning the first time they interact with a service provider and are referred to the appropriate unti or provided the service. Now service providers are making family planning demand generation a daily routine. The approach has enabled the city of Bouaké to improve their family planning indicators.
The TCI approach [which promotes collaboration between local government and the health system] has helped us a lot. If we can maintain this approach, I think the most significant change, what is most significant is sustainability. If we can maintain both aspects, the mayor’s commitment and the daily routine of ISBC, I think we can do it. – Dr. Bamba
It's now part of our daily routine, it’s done every day… You come and say: “Dr. Bamba, I have a headache.” I address your headache. As soon as I am done, I ask you three questions based on the job aid, which is right in front of me: “Madam, how are you? Do you know about family planning?” In case you say “yes,” [I will ask], “are you currently using a method?” If you say “yes,” I encourage you to keep using it and send you on your way. However, with ISBC, if you reply “No”, I ask “Do you want to be on any method? Yes?” I will explain it and tell you all about family planning. [If] I am a nurse and I can’t provide the method, I will refer you to the FP unit where a midwife or a physician will provide the method… The innovation is that it’s now part… of the daily routine. We are gradually integrating [family planning] into the daily routine at all entry points. – Dr. Bamba
This coaching and mentoring model provided relevant talking points to ASHAs to address any awkward queries that they might face while counseling men to adopt a family planning method and made them confident enough to visit chauraha meetings on their own. Moreover, the recognition of these nine ASHAs has motivated others. In just seven months, the male engagement strategy is now functional in 20 TCIHC-supported cities across Uttar Pradesh. The city data of Kanpur shows a 245% jump in the number of NSV acceptors from 47 in April-June 2018-2019 to 162 in April-June 2019-20. And, city administration has taken note of this difference made by the METL in coaching ASHAs on the male engagement strategy.
Recognizing Champions for Promoting Male Family Planning Method
Promotes male participation in family planning as part of the Government of India's family planning agenda Highlights how TCIHC helped cities to increase male engagement in family planning by coaching urban ASHAs Demonstrates ownership and sustainability
Meenakshi Dikshit, TCIHC Anil Kumar Dwivedi, TCIHC Pranav Jha, TCIHC
We found that majorly there were two issues why men didn’t seek family planning services. First, family planning is perceived as women’s responsibility as they give birth. And, second, there are multiple myths, misconceptions and social taboos around NSV. During our household visits, we counseled couples on the benefits of NSV and eradicated myths associated with male sterilization. – Recognized ASHA
Family planning benefits both partners in a relationship and either partner can adopt a suitable method to space or limit their family size. However, the responsibility disproportionately falls onto woman. The Government of India recognizes the role that man play in the family as family planning champions, supports and users. The city health administration of Uttar Pradesh promotes non-scalpel vasectomy (NSV) through designated NSV day on the 21st of every month but very few men show up. The city of Kanpur has faced the same issue, year-after-year. To address this, the The Challenge Initiative for Healthy Cities (TCIHC) in India launched an innovative “male engagement strategy” in January 2019 to promote male family planning methods, condoms and NSV. Under this innovation, urban accredited social health activists (ASHA) are coached and mentored by a Male Engagement Team Leader (METL) on how to engage and counsel men on family planning. The approach includes going to where men congregate and speaking with them there. This includes reaching men at chauraha (meaning cross roads in English), evening meeting points, workplace interventions, etc. The approach also targets specific populations, like rickshaw pullers. Among whom, the myths related to male methods are most prevalent. In addition, the approach includes counseling men during ASHA home visits. As a result of adopting this strategy, nine of Kanpur’s ASHAs were recognized on World Population Day (WPD) - July 11, 2019 - by the government for their efforts in identifying potential NSV clients and referring them to services. This strategy has helped Kanpur to become second in the state for most NSVs. Just on WPD alone, 155 NSVs were performed compared to 75 NSVs performed during WPD 2018.
ASHAs are women and mostly interact with women. Initially, we were not comfortable that they visit chauraha and talk with men on such a sensitive issue, but they have done a commendable job and have given result. Thanks to continuous coaching and mentoring provided to them by TCIHC. – Additional Chief Medical Officer and Nodal NUHM Kanpur
Mobilizing Access to Family Planning Services Through Religious Leaders
Highlights the importance of using religious leaders as social mobilizers in some contexts Demonstrates community involvement in the health system Exemplifies the importance of proper mobilization, planning and community involvement to ensure the success of in-reaches
Onyedikachi Ewe, DG-TSL Anambra
Pastor Kenneth Dike is a religious leader and TCI-trained social mobilizer as well as resident of Bida community, Onitsha South local government area (LGA), Anambra state. Pastor Ken, as he is popularly called, has always had a passion and zeal for free family planning services to be rendered in his community because he is well-aware of the needs of his community members. Bida is an urban slum located in Onitsha South, characterized by very low-income households with large families of 7 to 9 poorly spaced children. In Onitsha South, there are not many trained providers or health facilities offering family planning services. In November 2019, TCI initiated a facility-based in-reach campaign with LGAs and requested them to self-select locations for the activity. In-reaches are conducted in hard-to-reach communities. The state mobilizes all of the required equipment and supplies as well as additional service providers to ensure quality family planning services. During these in-reaches, the state government provides consumables for the uptake of family planning services. As a result, uptake of family planning is truly free during in-reaches. The Reproductive Health (RH) supervisor for Onitsha South, together with the social mobilization officer, social mobilization assistant and Pastor Ken (serving as a mobilizer) selected Sokoto Health Post, Bida. When Pastor Ken got information on the approval of the location for the In-reach, he started creating demand and visibility for the health facility. With his own funds, he designed a banner, which was displayed in front of the health post days prior to the event. He engaged members of his church to conduct thorough sanitation in and around the facility to ensure potential clients would find a welcoming environment on the day of the in-reach. On the day of the in-reach, he provided fuel for his personal power generator which was used to power the clinic from 8am-4pm to ensure a conducive environment for clients and providers. In an interview with the RH supervisor conducted by TCI, she said that insertion couches were also donated to the facility by Pastor Ken for the in-reach. As a result, 17 women obtained a long-acting, reversible contraceptive method at the clinic. In addition, the increased awareness about family planning and child birth spacing achieved in the Bida community cannot be overemphasized. Community members now know that they can take up a family planning method to space or limit the number of children that they have. Some of the women who spoke after obtaining their method of choice could not control their joy and happiness as they didn’t believe anything could be done about childbirth spacing except refusing their husbands sex, which was always a source of dispute in their families.
Ogu ime abani anaa.’’ [“There will no longer be fights or disagreements at night”.] – woman and new LARC user